The Role Of The Pediatric Nurse In Discharge Planning ; Identifying Gaps In Sri Lanka

: 25 November 2020 : 14 February 2021 : 17 February 2021 Abstract Background: Pediatric discharge planning is a complex process, and that nurses need lengthy preparations. Role confusion among nurses will disrupt the smooth planning of the discharge. In Sri Lanka, although there is a possibility of reducing health costs through effective discharge planning led by pediatric nurses, it is questionable whether Sri Lankan nurses have clarified their role in this process. Method: This systematic review was conducted to map the different roles of nurses in the pediatric discharge planning process. Electronic databases of PubMed and CINAHL were searched for peer-reviewed journal articles among the pediatric population from 2005-2019, using the keywords such as discharge planning, pediatric nurse, care transitions, transitional care, and Sri Lankan nurse. Results: Articles that resulted in the word combination ‘Discharge planning and pediatric nursing (n=329) were used for screening. Two hundred and forty articles out of the nursing scope and sixty articles that do not describe an apparent nursing involvement in the discharge process were excluded, based on abstract review and full-text review, respectively. Sixteen studies were included in the final review. Few literature was found on the topic among Sri Lankan pediatric population. Four main categories of nurses’ roles were identified with the thematic analysis: discharge educator, discharge collaborator, post-discharge care coordinator, and family counselor. Conclusion: In Sri Lanka, no such defined roles of a nurse have been established yet in the discharge planning of pediatric patients. These roles may help nurses carry out discharge planning effectively, and future studies are needed on this topic in Sri Lanka.


INTRODUCTION
The discharge planning concept originated in The United States in the 1960s provides safe care transitions from hospitals to homes or another health care facility using multidisciplinary approaches (Lin et al., 2012). Discharge planning has become an integral part of the care coordination of the patients due to the fact that proper discharge planning and adequate discharge readiness reduce the length of stay at the hospital, readmission rates within 30 days of hospital discharge, health costs, and post-discharge complications (Jack et al., 2009;Weiss et al., 2014;. Nurses played an essential role in the discharge planning process and included the concept in their care planning since the 1990s (Lin et al., 2012). Some studies identified nurses as "transitional coaches" to manage discharge planning activities (Rosenbek & Coleman, 2013). Nursing care is pivotal not only in the discharge process but also in the post-discharge phase (Aued et al., 2019;Naylor et al., 1999;Popejoy et al., 2012). Discontinuity from the inpatient care causes post-discharge complications in 50% of the adults discharged from hospitals because discharging from hospitals is a vulnerable situation for patients and their families (Kripalani et al., 2007). Productive nursing care, which includes discharge readiness assessment, has decreased the readmission rates of adult patients (Yakusheva et al., 2019). Adult studies have found that nurses integrate various discharge planning activities during their care provision (Foust, 2007) and the effectiveness of such activities (Naylor et al., 1999;Zhu et al., 2015). Attitudes of the family affect the efficacy of discharge planning (Chang et al., 2016;Koné et al., 2018), and medical team collaboration is essential to prevent premature discharge (Ofoma et al., 2018).
Although there are still limited studies about discharge planning, the discharge planning interventions led by nurses in the pediatric setup have proved their effectiveness in maintaining care continuity and providing support for families. Such interventions include family conferences, follow-up visits, phone calls, and combining with community care Baker et al., 2016;Pickler et al., 2016). Parents have concerns about healthcare delivery by health professionals, including nurses, in their child's care plan (Brenner et al., 2015). The health care team should always focus on the caregiver or the family along with the patient care. Providing adequate discharge information to the caregiver can reduce the complications during home care (Driscoll, 2000). In the pediatric setup, the family plays an essential role in the discharge plan as the family is constant in the child's life and the child's sole caregiver. Pediatric patients' discharge from the hospital is stressful for both the child and the family, including siblings. Families need time for adapting to the new reality; therefore, the pediatric discharge process requires time and lengthy preparations (Bowles et al., 2016;Brenner et al., 2015;Purdy et al., 2015).
Nurses have frequent interactions in patients' hospitality compared to other multidisciplinary team roles (Watts & Gardner 2005). Inadequate clarifications of the multidisciplinary team and confusion of their roles have been identified as barriers to effective discharge planning (Wong et al., 2011).
Being a developing country where the government provides health for every citizen at free cost, the massive health-related goal is a burden for Sri Lanka. Interventions that will lead to the reduction of health costs and readmission rates are in utmost need. In Sri Lanka, although nurses involve in the discharge process, their role has not been clarified well due to the lack of conceptualized guidance and very few engaging in the specific role (Coleman et al., 2005;Hettiarachchi & Amarasena, 2014;Senarath et al., 2007). This review mainly focuses on mapping the different roles of the nurse in the discharge planning process in the pediatric setup.

METHODS
This literature search was done in the electronic databases PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) through Hinari Research in Health. The search was performed in May 2020 using the search terms; "Discharge planning, care transition, discharge planning guidance, discharge planning and nursing, discharge planning and pediatric nursing, discharge planning in Sri Lanka".
The study included Peer-reviewed journal articles published from 2005 to 2019 in Pediatric setups. Full-text English articles were refined. Quantitative studies, qualitative studies, and mixed-method studies were included. Reviews, case reports, studies on medication trials, microbiological studies, studies conducted in the Emergency Departments, studies that describe only postsurgical management and rehabilitation were excluded.
Articles that describe nurses' involvement in the discharge process or post-discharge phase were included in the final review. Reference lists of each

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38 article were screened manually. The contents of the articles about studies on Emergency departments were again screened carefully to clarify whether they describe a clear nursing role in the discharge process or post-discharge phase.
PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were used for data screening. The articles resulting from the search term "Discharge planning and pediatric nursing" were exported to Mendeley Desktop. Their titles and abstracts were screened to identify those reporting on original research, followed by a fulltext screen of the remaining articles to determine which articles to include in the study. Duplicate articles were removed. Due to the lack of recent literature on this topic in Sri Lanka, internet websites were searched for additional information. Both authors followed this method to screen the articles and check for gaps and discrepancies in their search results. Figure 1, the PRISMA flow chart, represents the method of literature searching and article selection.
Since the study was confined to peer-reviewed journal articles, no special quality appraisal tools or guidelines were used to measure the quality of the articles. Data from the finally selected articles were extracted into an excel spreadsheet. Then data was systematically organized, compared, and contrasted by two authors to identify nurses' roles in the discharge planning from the contents of the studies using thematic analysis by the General Inductive Approach. The inductive analysis allows the origination of concepts and themes through deeply reading the raw data (Thomas, 2006).
Finally, the authors read selected articles several times separately, and text segments that explain the nurses' involvement in the discharge process were highlighted and expressed in the narrative form. The highlighted text was exchanged among the authors. Core meanings evident in the text relevant to nurses' involvement in the discharge process were identified by two authors. The highlighted text segments provided a foundation to recognized categories. Sub-themes and themes were developed based on the deep analytical thinking on the relationship among the categories.

1.Discharge Educator
Nurses play a significant role as educators in the discharge planning process, both in inpatient and post-discharge care. This education follows the family system approach filling the parents' knowledge gaps and covers the following subcategories.

Medications and Red flags
Educating the child, family, or caregiver about medication dose, timing and side effects, and the complications that may arise that need prompt medical assistance will help ensure the child's safety in the post-disharge period. 'Road to home' program by Smith (Smith et al., 2018) includes a tool kit that helps to address medication issues and emergencies after discharge and discharge education curriculums may include emergency management kits for the caregiver (Gallotto et al., 2019).

New skills for the caregiver
The child may need complex treatment plans even after hospital discharge. Thus, it is a must to ensure that the caregivers can demonstrate the skills necessary to continue the care provided at the hospital after the discharge (Schuh et al., 2016;Wells et al., 2017;Smith et al., 2018). Nurses should have a keen knowledge and skills on teaching methods such as explanation, observation, execution, supervision, collaboration, and assessment to provide those skills for the caregivers. These skills include technical, medication administration, nutrition, and hygiene (Gallotto et al., 2019;Góes & Cabral, 2017). Learning new skills that help to care for their child by themselves will increase the parents' confidence (Dellenmark-Blom & Wigert, 2014).

Life after discharge
Parents and children perceive that having a clear understanding of life after discharge will easily help them achieve expected goals (Weiss et al., 2017). Nurses can provide discharge teaching about life after discharge to carry out proper discharge planning (Holland et al., 2015;Lerret et al., 2017). Furthermore, parents and clinicians see nurses as the best professionals who can provide the necessary instructions regarding life at home once the child is discharged from the hospital (Góes & Cabral, 2017). Pre-discharge education should focus on the community services available for the family to seek help after discharge when needed (Schuh et al., 2016).

Written information
Providing written information through handbooks, booklets, flyers during the educational sessions will improve nurse and parent satisfaction (Ekim & Ocakci 2016;Gallotto et al., 2019;Smith et al., 2018). The nurse is responsible for ensuring whether the family or the caregiver has understood the provided written information (Pfeil et al., 2007).

Discharge collaborator
Collaboration between nurse and wide range of parties were identified during the review of evidence. The main category was again divided into the following subcategories.

Social and community workers
Nurses are in the frontline to mediate care between family and the social workers (Smith et al., 2018). Public health Nurses, like Home visit nurses, play an essential role while interacting with necessary officials in order to receive assistance for the family. These include utilizing financial and social resources available in the community to fulfill post-discharge care needs (Wells et al., 2017).
2.2 In-hospital medical team Efficient collaboration with health providers inside the hospital will allow more opportunities for nurses to involve in the patient discharge planning, which increases patient and family satisfaction Góes & Cabral 2017;Holland et al., 2015;Uspal et al., 2016;Smith et al., 2018). This collaborative work will work towards speeding up the recovery of the child (Wells et al., 2017). The nurse should effectively communicate with necessary health professionals to fill knowledge gaps of the patient and family (Gallotto et al., 2019).

Family and the caregiver
Parental self-efficacy perception (Ekim & Ocakci 2016), satisfaction (Arad et al., 2007;Uspal et al., 2016;Smith et al., 2018), experience with home care (Dellenmark-Blom & Wigert, 2014;Lerret et al., 2017), perception on care received (Pfeil et al. 2007), care giver's comfort and needs (Gallotto et al., 2019;Góes & Cabral, 2017) have been assessed because every discharge planning intervention needs collaboration with a parent, caregiver or the family of the child (Weiss et al., 2017). Assessment of discharge readiness of the patient and family is an essential aspect of the discharge process, which needs interactions with them throughout the stay (Schuh et al., 2016). Collaboration between nurses and the family will help nurses identify the parenting roles' strengths and weaknesses and prepare interventions to address the issues, including sibling needs (Dellenmark-Blom & Wigert, 2014;Lerret et al., 2017).

3.Post-discharge care coordinator
Nurses carry out post-discharge care coordination to ensure the care continuity of the child under two subcategories. 3.1 Home visiting Home visits led by nurses allow them to assess the child's home environment, the child's safety at home, the child's physical well-being and make NURSING PRACTICES necessary modifications collaborating with the family members (Ekim & Ocakci, 2016;Pfeil et al., 2007). These visits will help nurses identify the family's social, emotional, and financial issues and refer them to necessary professionals. Home visiting is an opportunity to evaluate the discharge education provided at the hospital and renew parental knowledge on the child's treatment course (Meerlo-Habing et al., 2009). Since family is a constant in the child's life, being at home with the family will help the child emotionally; therefore, early discharge can be implemented if the nurses are allowed for home visiting once the child's discharge (Pfeil et al., 2007;Wells et al., 2017). Parents may feel uncomfortable in the common discharge education sessions at the hospital (Smith et al., 2018) but feel more comfortable at their home being more open to the nurse disclosing their concerns (Dellenmark-Blom & Wigert, 2014;Pfeil et al., 2007). The feeling of being cared for even after hospital discharge will enhance parental emotional stability (Dellenmark-Blom & Wigert, 2014;Lerret et al., 2017).

Telephone counseling
Frequent contact with the nurse and the parents after discharge will increase nurse and parent satisfaction (Pfeil et al., 2007). These contacts allow the family to discuss their problems and resolve them with the nurse. Every discharge planning model should include counseling sessions to ensure continuity and the quality of the care provided (Ekim & Ocakci 2016;Wells et al. 2017). Telephone call follow-ups will help families to return to their regular routine easily Pfeil et al., 2007) and help health professionals to evaluate the effectiveness of their discharge planning interventions (Arad et al., 2007).

Family counselor
Nurses function as supporters for the family to identify their concerns and solutions, implying a counselor role. This role can be described under two sub-categories.

Emotional support of parents
Parents are facing a variety of challenges once the child is again at home after discharge, including balancing the care of the child and sibling needs, establishing a new routine, lack of sleep, fatigue, anxiety, fear of child's future, attending school needs of the child and follow up appointments (Dellenmark-Blom & Wigert, 2014;Lerret et al., 2017;Meerlo-Habing et al., 2009). The nurse can help them anticipate these issues in the discharge education process and find solutions early (Ekim & Ocakci, 2016;Gallotto et al., 2019;Turrell et al., 2005;Smith et al., 2018). Then the families will feel safe and prepared for the encountered problems. The reassurance gained from the nurse in the postdischarge period also reduces parental stress (Arad et al., 2007;Dellenmark-Blom & Wigert, 2014;Góes & Cabral, 2017;Pfeil et al., 2007;Schuh et al., 2016;Wells et al., 2017).

Siblings' needs
Siblings may feel neglected and less attentive with a sick child at home . Nurses can involve in such situations to increase support from other family members or finding a home care nurse for the family (Wells et al., 2017;Smith et al., 2018). During the assessment of discharge readiness, siblings' readiness also should be assessed (Schuh et al., 2016).

DISCUSSION
As previously discussed, a transition from hospital to home will be an anxiety-provoking situation for the sick child, parents, and other family members (Purdy et al., 2015). However, with proper transitional care, it can be turned into a situation where the clients see it positively, again more than a loss and an opportunity more than a crisis (Chick & Meleis 1986). This systematic review has identified different nursing roles in the pediatric discharge planning process, bringing positive outcomes for transitional care, and needs to be incorporated with the Sri Lankan context. Out of the studies that we have selected, most studies have been conducted in the USA, where discharge planning emerged. Studies in Asian countries were hardly found during the literature search on the topic.
If the nurses cannot provide adequate information and reassurance for the patients and family, their uncertainty will lead to unnecessary utilization of health care facilities. Parents' health literacy is essential in the disease prevention of children (Sanders et al., 2009). The discharge educator role was found in most of the studies, which implies the need for more time for nurses for educational sessions for the patient and the family. An educator nurse should have teaching skills and sound knowledge of educational theories, knowledge of family-centered care approaches, and related practices. In Sri Lanka, nurses' shortage of nurses and increased patient turn-over rate have led to a situation where nurses work under stressful conditions with a heavy workload (De Alwis & Shammika., 2015;De Silva & Rolls., 2010). It is a challenge for Sri Lankan nurses to spare adequate time for discharge teaching in such a situation. Although the nursing training schools have included the patient teaching methods in their curriculum, there will be a gap between the nurses' knowledge and the practice when it comes to the actual practice.
The middle-range theory of transitions developed by Meleis et al. (Chick & Meleis 1986) describes that the community in which an individual belongs and its resources will significantly affect his/her transition from hospital to home or another health care facility. Therefore, nurses involved in discharge planning should collaborate with necessary parties in the community where the child and the family belong. These may include welfare services, school officials, religious leaders, co-workers of the parents, and relatives of the family. The nursing role as a collaborator implies the need for communication skills for nurses. During discharge planning, communication with the community care sector is essential. Nurses should have sound knowledge of the available facilities and contact methods in the community. Maintaining better continuity of care, communication, and interaction between the health professionals is essential (Page et al., 2016). This collaboration should not be confined to the community outside the hospital but also with the persons involved in the child's care during the hospital stay.
Our study also found that nurses could function as counselors and post-discharge care coordinators. These skills can be incorporated into nurses and other health professionals (Maguire & Faulkner, 1988). As we found, nurses can coordinate postdischarge care through follow-up home visits and telephone counseling. New nursing specialties such as family care nurse, public health nurse home visiting nurse have emerged along with the discharge planning nurse (DPN) profession due to the increasing need for adequate post-discharge care. Care coordination through telephone counseling might be a challenge for nurses in some communities due to the lack of access to the facility and lack of literacy of the clients. In previous literature, the nurse's counseling role is limited to school nurses and community care nurses (Alizadeh et al., 2011). Since counseling is a broad area of practice with ethical concerns, necessary skills should be possessed by nurses to provide quality care. Therefore, these aspects should be included in the nursing curriculums and professional training to allow nurses to anticipate the issues and find solutions.
In terms of the sibling issue, they will have unmet needs such as communicating information, maintaining their usual daily routine, and activities with having a sick child at the hospital. They may undergo severe emotional crisis with loneliness, guilt, and jealousy where nurses should intervene the supportive acts (Wilkins & Woodgate, 2016). Nurses have a responsibility to help the siblings to master their ability to get accustomed to the new situation. The opportunity to engage in the care of the sick child during the stay and after the discharge will help siblings understand the reality of the transition they have to undergo with the discharge of the sick child. Discharge care should strengthen the family bonds and cohesion as the family relationships have been identified as an indicator for a successful transition (Chiang et al., 2012).
In recent years, with the increasing medical needs of the pediatric population, Sri Lanka has a massive burden in providing health care facilities (Ministry of Health., 2019). Therefore interventions which lead to reducing health cost while providing efficient care is in need. With the existing knowledge, it is obvious that proper discharge support will help to achieve this goal. Sri Lanka public hospitals do not include a separate department for discharge planning and the nursing specialty 'discharge planning nurse' still has not been well established in Sri Lanka. World Health Organization (WHO) has identified neonatal, infant, and under-five children's mortality rates as crucial health indicators of Sri Lanka (Ministry of Health., 2019), implying the importance of children's health.

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Long-term complications that may arise physically, mentally, and socially in children should be prevented as health issues in childhood lead to health problems in the later years of life affecting the future development of a country. In Sri Lanka, although pediatric nurses do not have a conceptualized guidance on discharge planning and discharge support, nurses function as information providers for the family. However, due to busy ward rounds and inadequate beds, discharge planning has neglected or unobservable in the ward setups. Only special care units provide follow up care, and written information for the discharging patients. Although specialties like diabetic education nursing officers (DENOs) have been established, those roles have been limited to adult care setup. There is no much evidence of studies on post discharge health care utilization of the pediatric patients in Sri Lanka. Home visits by nurses have been limited to public health sector and palliative care sector in Sri Lanka and due to the lack of adequate nursing staff in hospital setup interactions between nurse and the family have been limited. Family centered care practices are visible in some instances such as having one parent by child's side throughout the hospital stay, siblings visiting policies and attending the mother and the child at home by public health midwives. Therefore, Sri Lanka pediatric nurses may have knowledge on the importance of implementing discharge planning for pediatric patients but due to the role confusion and lack of guidelines, implementing the process in the real practice may have been a challenge for them.
There are two limitations of this study. Studies published only in English in two databases were considered, which may not account for studies on other languages. Moreover, grey literature was not considered.

CONCLUSION AND IMPLICATIONS FOR PRACTICE
According to our knowledge, very few recent literature is available on discharge planning support by Sri Lankan pediatric nurses. Therefore, more studies are needed on the topic in Sri Lanka. Policymakers should take the discharge planning process to their consideration to reduce health costs and care burden. In Sri Lanka, special pediatric nursing training is implemented only at a post-basic level under the supervision of the Ministry of Health. Thus, establishing the Discharge Planning Nurse profession in the pediatric setup is essential to widen the post-graduate educational opportunities for pediatric nurses. Our study has identified various nursing roles in the pediatric discharge planning process. These identified roles can be incorporated into the discharge planning interventions, models, and guidelines for Sri Lanka pediatric nurses in the future. It will give rise to new nursing trends and specialties in the Sri Lanka nursing profession.

DECLARATION OF CONFLICTING INTERESTS
The author(s) declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.